When asked how he deals with the ornery, miserable, nasty patient, a busy urologist relates that he tells them that their case is more involved than what he treats, and that he would like them to see another specialist in town who might be able to better deal with their problem. This way he avoids dealing with a patient who would make his life miserable. Directing the misanthropic patient to a teaching hospital or a boutique practice, where they have time to placate the difficult patient, relieves stress and burnout.

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It is extremely difficult to go through your lifetime of practice without incurring some adversarial relationships. You must avoid or mitigate such incidents to protect your reputation and the integrity of your practice. Doctors with great bedside manner have fewer incidents; however, it is inevitable that even they will not please everyone all the time. Learning how to handle adversarial relationships requires various strategies to defuse situations while maintaining your sanity.

There are several areas of human interaction that are prone to misunderstanding, disagreement, or conflict. Good communication skills are necessary to both avoid and remedy adversarial incidents.

OFFICE POLICY

Rules and policies must be established for an office to run properly. Policy and exceptions must be taught to your staff so you don’t have to handle every problem. Your policies should be flexible enough to show compassion without having patients take advantage of your kindness. An office that is too rigid tends to dilute the doctor’s efforts at bedside manner.

There are times you have to give in to patient demands, but it should be the exception; and when it causes tension between you and your staff, make sure you explain to them why you gave in and hear their point of view so that you remain attuned to their feelings.

Money Matters

Non-payment of bills or disagreement over fees for services rendered has great potential for adversarial conflict. Strict monetary policy makes matters worse. Many patients leave a practice because of money issues. Exceptions should be made to help a patient who has financial problems, when fees weren’t clearly explained, or when insurance companies don’t pay what was expected. Certainly, you don’t want patients to take advantage of your goodwill, but any financial policy needs to have some flexibility.

If you explain to your staff in advance those situations where payment policy may be changed, you won’t be undermining their authority at the front desk. Helping a needy patient through a difficult time may be the best booster for your bedside manner as it personifies compassion. Offering a refund for a failed procedure doesn’t have to be construed as an admission of guilt. It can be a wonderful practice booster for the patient who may not have understood the prognosis issues related to their treatment.

Financial policy exceptions need to have limitations. You don’t want to become the neighborhood banker. Sadly, some people pay bills that have to be paid and put off payment to the good-hearted doctor who doesn’t have any policy about collection of fees.

Scheduling

Coming late to appointments and repeatedly missing appointments leads to adversarial relations. It is important to identify those patients who are repeat offenders and utilize scheduling remedies noted in the post on the waiting room.

Rather than sending a late patient home, it may be best to have them seated and let the doctor do a cursory exam and explain why he needs them to return and be on time so he will be able to accomplish the procedure.

DOCTOR

“We’re lucky that today I only had to do a minor procedure. Next visit, I need much more time so please don’t be late for that appointment.”

I worked for an office that refused to see patients if they came more than fifteen minutes late. Since each visit was scheduled for thirty minutes, it could be argued that it was reasonable enough to reappoint patients coming that late. While sitting around reading a magazine, waiting for my patient, I heard her arrive and explain to the secretary how she waited in the storm for the bus to come, and it was running late. The secretary proceeded to tell the patient she would have to reschedule. I intervened and told the patient I would see her. Naturally, the secretary wasn’t very happy.

Had I let the secretary turn away this old woman, drenched by the storm, I would have validated the poor reputation this office developed over the years. You have to have a heart and not worry so much about going to lunch late. Better yet, in your office, set up policies that prevent adversarial situations.

PATIENT BEHAVIOR

The Dictating Patient

Numerous patient behaviors result in conflict. There are those who like to dictate treatment. The patient can refuse treatment, get other opinions, or not follow directions; but dictating treatment is not permitted. This doesn’t mean the doctor shouldn’t be open to patient suggestions or ideas they may have garnered in some alternative therapy search. Showing interest in their ideas makes them feel validated in spending the time to do the research, while disregarding or mocking their efforts lends toward bad feelings.

You cannot let a patient dictate malpractice. If the patient says they want you to perform a procedure in a manner that you know is malpractice, having them sign a waiver does not remove your liability. A patient refusing x-rays is a common example. A signed waiver doesn’t excuse the doctor’s responsibility when untoward results occur from not having the proper x-rays.

The Nasty Patient

An experienced psychologist:

“I have been taught never to try to reason with an angry or irrational patient, it just doesn’t work. What I will use is a ‘joining technique’ simply trying to join with the patient where he/she is at with the anger that they have. It shows the patient that you not only hear what they are saying but also that you understand what they are feeling.”

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Truly belligerent patients should be dismissed from your practice. You can’t please the world and there is no reason you need the added stress of an inconsiderate, nasty person unless you like the challenge.

Staff will often run back to warn doctors about some terribly obnoxious patient. These patients may be on antidepressants or other psychotropic drugs. They may have some personality disorder that makes them adversarial with most of the people in their lives. Make your staff aware of such personality types and how to recognize them by reading their medical history and noting the medications they take. Your staff will be better able to deal with the belligerence knowing there is a medical reason for the abhorrent behavior. Quite often patients who act antisocial are bipolar, depressed, or dealing with some such illness. Some are diagnosed as having borderline personality disorders. Make sure you know what this means as it will help you to understand their behaviors. Others may just be miserable, have low tolerance for stress, or they may be inconsiderate of others. Once you and your staff recognize this reality, you will not take affronts personally.

The Let’s Make A Deal Patient

Some patients may try to bargain for services. You have the option to make deals, though that may not appear very professional. Hopefully, your fees are based on the value of the services rendered and should not be discounted except for financial hardship or perhaps as a discount for multiple procedures. The best way to handle a bargaining patient is to explain that your fees are the same for everyone and that if you were to offer a discount to one patient you would have to offer it to all patients to be fair. You may want to have senior fees for the elderly who rather often ask if they are available. By offering compassionate answers to patients’ requests, you keep your bedside manner intact even if you don’t give the patient the answer they desire.

The Nasty Letter

When patients make written complaints against you, your staff, or office policies, it is best to respond personally to their concerns either by phone or by mail. Avoid making incriminating statements that can be used against you in court, but don’t be afraid to defend your polices in a professional and respectful manner. If the patient complaint is justified, be willing to apologize for inappropriate policies, staff behavior, or personal behavior. Patients will appreciate the time you take to respond, and many times you can resolve the misunderstanding and retain a patient who becomes loyal and admiring rather than the one who makes negative comments all around town. If you don’t have the time or the ability to respond personally, have a highly competent, compassionate staff member take on the responsibility. Always document in the patient chart any response you or your staff make by phone.

STAFF

Some would argue that relations with staff shouldn’t affect bedside manner, however, if your staff isn’t on your side, they can convey negativity to patients either subconsciously or overtly by making negative comments. Negativity always undermines the doctor-patient relationship by placing doubts as to why others may not like the provider.

This not being a treatise on salaries, raises, benefits, and other staffing issues. Suffice it to say negative behaviors or comments by staff should not be tolerated. Most doctors who have great bedside manner are usually warm and caring to their staff, and the staff is usually very fond of the doctors. This positive relationship is conveyed to the patients either overtly or subtly in the way they show respect. A positive relationship with staff validates the patient’s good feelings about the doctor.

You have to be creative in order please your patients and staff. You need to have them both on your side.

The patient is always right philosophy is a detriment to relationships with staff. No matter what the staff says regarding policy, if the patient complains, and the doctor acquiesces, the staff may become furious, and justifiably so.

In cases where you let the patients have their way, they will love you. However, catering to pushy patients will invariably inconvenience others. There are times when you should get rid of adversarial patients who can’t get along with your staff and abide by your policies. A happy staff is much more important than a few happy dysfunctional patients.

COLLEAGUES

Negative comments about other professionals are not appropriate. While some health-care providers feed upon making negative comments about colleagues to make themselves look superior, it is not professional or ethical. It does get some patients to assume you must be very good since you recognize the failings of the other provider, but it also undermines the profession making patients believe other doctors are incompetent. Unless you know the circumstances of the other doctor’s relationship with the patient, you cannot comment fairly.

If you find a colleague who invariably provides poor advice or treatment to common patients, you have a duty to contact this provider to make sure your judgment is valid, make recommendations, and if problems continue, consider a report to the medical board.

If a colleague contacts you in an adversarial manner, maintain a professional demeanor, listen to the complaint, and indicate you will respond to the issue after some thought. It would be best to get counsel from other colleagues if the complaint regards treatment protocol. When you get back to the provider, you can have your response and remedy well thought out and organized.